This form was created to help you verify your insurance benefits.
Please have the following information available when calling your insurance company:
Our information is the following:
I understand that the above is an estimate only. I understand that I am financially responsible for any balances, after insurance pays, and that they must be paid within 10 days. Full payment will be required at the time of pre-op appointment, if this form is not completed in its ENTIRETY.
Colonoscopy (we are in network with Cigna BCBS, and Aetna) WE ARE OUT OF NETWORK WITH ALL OTHERS:
Procedure Code (CPT): 45378
Diagnosis (ICD-IO): Z12.11
Cost of Procedure: $1885.00
Please be advised that the CPT code and cost above are only for SCREENING COLONOSCOPY, if a polyp or other condition is found, your procedure and diagnosis code will change.
This will deem your colonoscopy MEDICAL and other benefits may apply.
Procedure Code (CPT): 45380
Cost of my procedure: $2300.00
Possible diagnosis (ICD-10): D12.0-D12.9 (specific code is dependent on location of neoplasm found
Procedure Code (CPT): 45385
Cost of my procedure: $2671.00
Possible diagnosis (ICD-10): D12.0-D12.9 (specific code is dependent on location of neoplasm found
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